All Intraosseous Sites Are Not Equal

Transcription

1 All Intraosseous Sites Are Not Equal Clinical Data Suggests the Sternal IO Route Improves Patient Outcomes Current Guidelines, (such as AHA) indicate that Intraosseous Infusion (IO) is a rapid, safe and effective alternative to IV (intravenous) infusion for the administration of fluids and medications. Recent studies highlight the importance of getting critical medications into the central circulation faster, and in higher concentrations, during cardiac arrest. Still more studies indicate that the sternal approach for the deployment of IO may be more effective in accomplishing this than when deploying IO infusion via other sites (body locations, such as the tibia). These differences may be critical in increasing survivability and reducing mortality when treating patients with cardio-pulmonary resuscitation (CPR) in non-shockable cardiac arrest rhythms (pulseless electrical activity and asystole). Recent studies indicate that the sternal approach for deploying IO may be more effective to get critical medications into the central circulation faster, and in higher concentrations, during cardiac arrest. PM-184b

2 Background: The Importance of Time in Cardiac Arrest Patients: Improved patient survivability after cardiac arrest requires rapid therapeutic interventions including CPR, defibrillation (when indicated) and administration of epinephrine and other cardiac medications. Data has shown that, during cardiac arrest, seconds count and rapid appropriate intervention saves lives. Many studies have documented the challenge of obtaining intravenous access as well as the detrimental impact of slow circulation times when a patient is in cardiac arrest. The rapid administration and availability of epinephrine and other cardiac medications leads to improved patient survivability. Supporting Data and Research: 1 Pharmacokinetics of Intraosseous and Central Venous Drug Delivery during Cardiopulmonary Resuscitation - by Stephen Hoskins, et al. (1) This study used a porcine model in cardiac arrest to study the time and concentration of a dye to appear in the arterial circulation when administered by sternal IO, tibial IO and central venous (IV) line techniques. The study demonstrated that: Mean time to maximum concentration was 53±11 s utilizing sternal IO deployment compared to 107±27 s when using tibial IO deployment, an efficacy increase of 54±16s using the sternal route. Mean time to half (50%) maximum concentration was 22±3 s using the sternal route and 50±8 s for the tibial route (p = 0.006), an efficacy increase of 28±5s using the sternal route. Times for tracers to reach their 50% maximal concentrations were 36±4 s for sternal IO and 30 ±4 s for the central vein routes (p = 0.06), an efficacy increase of 6±0 using the sternal route. The tibial IO route delivered less dose to the arterial blood or 65±5% as compared with the sternal route (p = 0.003). Based on the present data, we recommend that sternal IO route be considered as the first choice of drug delivery during CPR when IV access has not been established (1) This paper states: Based on the present data, we recommend that sternal IO route be considered as the first choice of drug delivery during CPR when IV access has not been established, and that the tibial IO route is also justified as second choice. 2 Intraosseous Infusion Rates Under High Pressure: A Cadaveric Comparison of Anatomic Sites - by Jason Pasley, et al. (2) This study used human cadavers and commercially available IO infusion devices: sternum (FAST 1), humeral head (EZ-IO), and proximal tibia (EZ-IO). Sequentially, the volume of 0.9% saline infused into each site under 300 mm Hg pressure over five minutes was measured. Rates of successful initial IO device placement and subjective observations related to the devices were also recorded.

3 The mean (SD) flow rate infused at each site was as follows: 1. Sternum, 93.7 (37.9) ml/min 2. Humerus, 57.1 (43.5) ml/min 3. Tibia, 30.7 (18.7) ml/min The tibial site had the greatest number of insertion difficulties. During the five minute infusion period, the total volume of fluid infused was 469 (190) ml for the sternum, 286 (218) ml for the humerus, and 154 (94) ml for the tibia, p<0.001, thus illustrating statistical significance....the sternal IO site provided the highest flow rates compared with the humeral and tibial insertion sites. The sternal site was also associated with a 100% success rate for initial placement facilitated by its consistent anatomy. (2) Reference for graphs above: - Intraosseous infusion rates under high pressure: A cadaveric comparison of anatomic sites; Pasley, Jason, et al, US Air Force Center for Sustainment oftrauma and Readiness Skills, Baltimore, MD. J Trauma Acute Care Surgery The authors made the critical points that: Flow rates are influenced not only by resistance to flow through the IO device but also by resistance to flow through the bone marrow space, and the sternal access point using the FAST-1 demonstrated significantly faster flow than for the other sites tested using the EZ-IO likely because of more limiting differences in the physiology and bony structure at these infusion sites. The authors concluded that:...the sternal IO site provided the highest flow rates compared with the humeral and tibial insertion sites. The sternal site was also associated with a 100% success rate for initial placement facilitated by its consistent anatomy. Because of its central position, the sternal site likely requires shorter infusion tubing length compared with the tibia site, is less vulnerable to inadvertent dislodgement compared with the humeral site, and is less frequently compromised by traumatic injury. Based on this analysis, the sternal site seems to have the optimal flow rate for most adult resuscitations. The sternal site, in addition to the humerus, should be used over the tibial site when conventional venous access is unobtainable.

4 3 Comparison of Tibial Intraosseus, Sternal Intraosseus and Intravenous Routes of Administration on Pharmacokinetics of Epinephrine during Cardiac Arrest - by James Burgert, et al. (3) This study used a porcine model in cardiac arrest to study how long, and in what concentration, it took epinephrine to appear in the central venous circulation when administered by the sternal IO route, the tibial IO route, and peripheral intravenous (IV) techniques. The study demonstrated that: IV administration of 1 mg of epinephrine resulted in a serum concentration of 5.87 times greater than the tibial IO approach and 2.86 times greater than the sternal IO approach. The sternal IO approach yielded a higher maximum concentration of epinephrine compared to the tibial IO approach, although the difference was not statistically significant. Time to maximum concentration (Tmax) for the tibial IO approach had a mean of 156 ± 13 seconds; for the sternal IO approach a mean of 60 ± 42 seconds; and for the IV approach a mean of 78 ± 69 seconds. There were statistically significant differences between the Tmax of sternal IO and IV as compared to the tibial IO technique. There may also be a relationship between the anatomical location of the IO device and serum drug concentrations; the more distal the IO infusion site is from the sampling site, the longer concentrations of drug take to rise. (3) Reference for graphs above: AANA Journal - August Vol. 80, No. 4 - Special Research Edition S9 This paper states: There may also be a relationship between the anatomical location of the IO device and serum drug concentrations; the more distal the IO infusion site is from the sampling site, the longer concentrations of drug take to rise. Another possible explanation is a local vasoconstrictive effect of epinephrine in the bone marrow circulation impairing drug delivery to the systemic circulation. Epinephrine delivery may differ substantially from other drugs that have not yet been studied in a cardiac arrest scenario.

5 4 Time to Administration of Epinephrine and Outcome after In-Hospital Cardiac Arrest with Nonshockable Rhythms: Retrospective Analysis of Large In-Hospital Data Registry - by Michael Donnino et al. (4) This was a large study conducted over nine years at 570 hospitals, examining 25,095 patients that had in-hospital cardiac arrests outside of the ED, ICU or surgical and specialty units. Of these patients, 55% had systole and 45% had pulseless electrical activity. Results of the study indicated a stepwise decrease in survival in-hospital with each additional minute until the first administration of epinephrine: 929 (12%) survived when epinephrine was given in the first minute, 392 (12%) in the second minute, 305 (11%) in the third minute, 208 (9%) in the fourth minute, 335 (10%) in the fifth minute, 124 (10%) in the sixth minute, and 310 (7%) in the seventh minute or later (P<0.001). Earlier administration of epinephrine was associated with a higher probability of return to spontaneous circulation, survival in hospital, and neurologically intact survival. (4) Statistical adjustments and analysis were done to control for time delays related to the initiation of CPR on these patients. Reference for graph: BMJ 2014;348:g3028 doi: /bmj.g3028 (Published 20 May 2014) This paper states:...earlier administration of epinephrine was associated with a higher probability of return to spontaneous circulation, survival in hospital, and neurologically intact survival.

6 References: 1. Pharmacokinetics of Intraosseus and Central Venous Drug Delivery During Cardiopulmonary resuscitation (CPR); Hoskins, Stephen L, et al, University of Texas and Sao Paulo Medical School. Resuscitation 83 (2012) Access or purchase the full article at: 2. Intraosseous infusion rates under high pressure: A cadaveric comparison of anatomic sites; Pasley, Jason, et al, US Air Force Center for Sustainment oftrauma and Readiness Skills, Baltimore, MD. J Trauma Acute Care Surgery Volume 78, Number 2. Access or purchase the full article at: 3. Comparison of Tibial Intraosseus, Sternal Intraosseus, and Intravenous Routes of Administration on Pharmacokinetics of Epinephrine During Cardiac Arrest; Burgert, James, et al, Fort Sam Houston and Northeastern University. AANA Journal, August 2012, Vol. 80, No. 4. Access or purchase the full article at: 4. Time to Administration of Epinephrine and Outcome After In-hospital Cardiac Arrest with Non-shockable Rhythms: Retrospective Analysis of Large In-hospital Data Registry; Donnino, Michael W, et al, Beth Israel Deaconess Medical Center. BMJ 2014;348:g3028 doi: /bmj.g3028. May Access or purchase the full article at: The rapid administration and availability of epinephrine and other cardiac medications leads to improved patient survivability.. Presented By Dr. Alan Moloff: Colonel (US Army, Retired), DO, MPH - Medical Director, Pyng Medical The clinical studies and data referenced in this paper were summarized by Dr. Alan Moloff. Dr. Alan Moloff brings over 30 years of operational military medical experience. He is Board Certified in aerospace, undersea and disaster medicine. Colonel Moloff s final assignment encompassed four years as Commander ofthe Defense Medical Readiness Training Institute (DMRTI) where he focused on joint medical readiness, combat casualty care and the medical aspects of Homeland Security planning and training focused on CBRNE and complex disasters. (+1) (+1) facebook.com/pyngmedical